Analysis of the speech of dying patients with cancer on end-of-life decision making

Abstract

8216 Background: Patients with cancer approaching the end of life were interviewed to ascertain their views on the formulation of “do not resuscitate” (DNR) orders to guide policy. Methods: Consecutive eligible patients had semi-structured interviews which were recorded, transcribed, and subjected to qualitative analysis. Accrual ended when data saturation occurred, that is no new issues were being raised. Results: Twenty-eight patients, 13 females, 15 males (average age 61, range 39–79) were interviewed, 86% as inpatients, half with family members or friends present. All were Australian residents with English as their first language; 64% were currently married. The patients spanned 11 different cancers from which 23 (82%) died within 12 weeks of interview, including 4 within 1 week, with the longest survivor just over 6 months. Fourteen patients had a DNR order recorded in their file at interview and only 1 had not clearly specified their wishes at time of death. However, for 7 patients there were discrepancies between their views at interview and what was recorded. All but 4 patients understood the term DNR. Resuscitation was often spoken of as a medical intervention which may stop an appropriate peaceful death. The majority believed that the patient should make the DNR decision stressing the importance of individual autonomy but some preferred a shared decision with physicians or family. Patients said that being lucid was necessary for making DNR decisions. There was no consensus on the appropriate timing of a DNR discussion. Some favored no discussion. A minority favored a discussion early before possible mental incapacity, but those who supported holding the discussion when the issue became pressing wanted to spare patients the negative emotions of an earlier discussion. There was ambivalence about who should decide when to discuss, some believing it to be the patient's decision but others deferring to the experience of the physician. Conclusions: DNR policies must allow the flexibility to accommodate diverse individual patient wishes. Documentation of DNR orders can be problematic, both in accurately ascertaining patients' wishes, and accommodating changes that may occur. No significant financial relationships to disclose.